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JAN-17-2006 08:54 Service Station Systems 408 938 eeee P.05/12 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3A0 FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES W DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS,INDICATE PERMIT TYPE BELOW. <br /> _TANK RETROFIT —PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT--� ^)ti{.� <br /> +----------------- <br /> ---- <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE H <br /> F ; FACILITY NAME k.64 _ O i�I2T{PC�_ i-------------- PHONS_# f -...... <br /> A +-_'-------------1 r------ ......._- <br /> C 1 ------- WLC`'l.y <br /> L CROSS STREET <br /> I -------------- s6_c cake <br /> , <br /> ----------------------------------------------------------------------------------------------------------- <br /> TPHONE <br /> OWNER/OPERATOR <br /> Y metres Cosa S#25 v-,e— �b7� <br /> S <br /> C CONTRACTOR Ni,ME & v� PH <br /> 0 +-------------- S.�Sd l C� .srC1_--LF� S ---- ,�K C.• p( '} --E ------ ------------U�d� -- <br /> N CONTRACTOR ADCRS3S f: ------`-- -Ct- --- _.-.L- ------- CA LIC 9 403_I 84 O�ASS�, s Jb,+o �� <br /> T -------------------- �S_�_Q - ---�- -------------------------------- -------- -_ .iti---^L_-_-_•_--_-_ <br /> . p <br /> ' R INS--BR Si--e [�inh i�•yp .,j., w y��r a 1r�j,„ Tj q 6. .1 w0 '1314 <br /> D <br /> r RK COMP # ' <br /> A <br /> C ; OTHER INFORMATION <br /> T +-----------l---------C----------------------- --------------+---- <br /> X13 03 <br /> R +--- -------- - --- -- -- -- ---------------+ ----------4--------------------------- <br /> r I <br /> PHONE # <br /> ----------------------------------------------`----------------------------------------------- <br /> ilrlrlrr r rl, <br /> r lil,lr I Ilrirl , <br /> ' TANK ZD # TANK SIZE CHFMICALS STORED CURRENTLY/PREVIOUSLY DATE CST INSTALLED <br /> 39- <br /> T 39• <br /> N 39- A <br /> X 39- <br /> 1 <br /> 9- <br /> L i APPROVED v APPROVED WITH CONDITION(S; DISAPPROVED <br /> A i F EPSATTACHMENT WITH CONO:T!=5) <br /> N ; PLAN REVIEWERS NAME77... I�1 U y( �*16)6 <br /> narE � <br /> ---.r,rll,I I,rl llr ............ rrl,rlr,rrrr, <br /> APPLICANT MUST PSRFORM ALL WORK IN ACCORDANCE WITH SAN JOFQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN MAOCTN COUNTY, BNV;RONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSEq CERTIFIES TH£ FQ;.LOW;NG: "I C1~RTIFY <br /> THAT IN THE PERFORMANCE OF 7KS WORN FOR WHICH THIS PERMIT IS ISSUED, Z SHALL NOT EMPLOY ANY PERSON TN SUCH A MANNER AS I'0 <br /> BECOME SUBJECT TO WORKER'S COMFENSAT;ON LAW3 OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING; "I CERTIFY THAT IN THE PERPORMNC3 OR ^-HE WOR{ POP, WF7CK THIS PERMIT IS ISSUED,'I SHALL FMPF.OY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE I <br /> ------------------------------------------------------------------------------------------------------------------------------------ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> �b8 _ <br /> Name JAARtY WCJ1+6,tAkJ Address 0� kLLitkgAt-e— Phone <br /> Signature YNa�_a—zzu bti � <br /> rt�(LC{ S' ru�-� S C(5u� <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />